Analysis Contraception

Sex Sells Family Planning and Safer Sex: Why Aren’t We Using It?

Christopher H. Purdy

Use of erotic imagery to promote family planning (as opposed to HIV prevention) has been less the norm but this need not be the case.

Sex and sensual images have been used for years in developed countries to sell everything from beer and soft drinks to cars and hotels, yet in reproductive health we have shied away from doing this even though much of our work is aimed specifically at people who are having, or contemplating, sexual relations.

Can the promise of a better orgasm, or at least a fear-free sexual experience, improve the chances that couples will use family planning? If a couple is not afraid of getting pregnant or picking up a sexually-transmitted infection, will they enjoy the sexual experience more? And if they do, shouldn’t the reproductive health and family planning community capitalize on that and apply the lessons learned by the multitude of marketers who know that sex sells?

I realize that the idea is scary for those who worry that such strategies will promote sex. It is safer to keep family planning and reproductive health medicalized, sanitized and respectable.

But the last time I checked, young people did not call their friends to talk about their “reproductive health” or “contraceptive options.” They talk about their sex lives — and they talk about it a lot! More and better use of language, imagery and presentation of a sensual and even erotic nature will go a long way towards making family planning more desirable, even fashionable, especially among young people who are increasingly sophisticated in terms of marketing.

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Perhaps most importantly, people use products because of imagery and the aspirational qualities associated with it. I believe that if we start using the same tactics that have proven effective with other consumer goods to market products that are, in fact, all about relationships, love and sex, we will increase demand for these products.

A couple of examples:

For obvious reasons, condoms are a product easily promoted with sensual imagery, a fact that is now generally accepted by the reproductive health community. In Brazil and the Philippines, DKT International is using sexy imagery to sensualize and promote condom use. In the Philippines, DKT has promoted Premiere condoms in partnership with For Him Magazine, while in Brazil, steamy TV commercials and a sexologist blog combine erotica with practical advice promoting safety.

In Africa as well, condom programming has evolved. In Malawi, Chisango (which means “shield” in the local language) was launched in 1994 as part of an HIV prevention program, with a brand featuring a silhouetted image of a demure couple with a Zulu shield. It was a conservative brand for a conservative country. But by the mid-2000s, condom use among young men (one of the prime target groups of Chisango) was waning and research showed they rejected this now outdated brand, calling it “my father’s condom.” A new, more provocative brand was developed — a photo of a sexy woman from the waist down, revealing a shapely leg bared by a slit in her dress. The image set off a bit of a firestorm. The National Censorship Board declared the image “obscene” and it had to be taken off outdoor billboards. But it was allowed to remain on the package and in other advertising and promotion. The negative publicity actually helped sales.

Use of erotic imagery to promote family planning (as opposed to HIV prevention) has been less the norm but this need not be the case. In Indonesia, DKT International has used sensual images of a couple on a bed, legs entwined, to promote emergency contraception. Also in Indonesia, DKT has used the promise of a better sexual experience to promote intrauterine devices, counseling men in ads that IUDs do not take away any pleasure from intimacy.

Those of us in global health need to be willing to meet consumers closer to where they are living, thinking and having sex when we promote family planning and reproductive health.

Roundups Sexual Health

This Week in Sex: At-Home STI Tests, New Virus-Killing Condom, and More

Martha Kempner

This week, LA County is reviving an at-home STI testing service, a new study shows that male circumcision can reduce rates of HIV among women as well as men, and an Australian company gets approval to produce a microbicide condom.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

LA Considers Bringing Back At-Home STI Tests

With both chlamydia and gonorrhea rates on the rise, the Los Angeles County Health Department is once again trying to promote the availability of at-home testing for sexually transmitted infections (STIs). The program began in 2009 when the department bought 10,000 kits for about $450,000 and advertised their availability to women ages 12 to 25. The goal was to increase testing and treatment among young women who did not have easy access to clinics or other health-care providers. About 9,000 kits were distributed. Most were sent back to the department for testing, and of those sent back about 10 percent tested positive for chlamydia and 3 percent for gonorrhea. But a health department official told the Los Angeles Daily News that after the first few years, interest in the program waned.

Since that time, rates of both STIs have increased in the county. Between 2009 and 2013, cases of chlamydia rose by 8 percent, while gonorrhea rose by 45 percent. These changes show that the STI epidemic in the county is worse than in California as a whole; during the same time period statewide, cases of chlamydia actual fell slightly and rates of gonorrhea rose by 13 percent.

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Both chlamydia and gonorrhea are bacterial infections that are spread through genital secretions during oral, anal, or vaginal sex. They often have no symptoms, though they can cause some discharge and/or burning during urination in both men and women. Both can also be treated with antibiotics but if left untreated can cause pelvic inflammatory disease (PID), which in turn can cause scarring in the reproductive tract and infertility, mostly in women. An estimated 2.86 million cases of chlamydia and 820,000 cases of gonorrhea occur each year in the United States. Between 10 and 15 percent of chlamydia cases in women cause PID. Because most cases are asymptomatic, the Centers for Disease Control and Prevention (CDC) recommends annual chlamydia screening for all sexually active females 25 and under and for women older than 25 with risk factors such as a new sex partner or multiple partners.

At-home testing can be done by collecting a urine sample or using a cotton swab to collect secretions from the upper vagina. The sample is then sent to a lab. In the LA County program, women get their test results either through a website or via text message. Those who test positive are then told where they can go to get the antibiotics they need. Dr. Jonathan Fielding, director for the LA County Department of Public Health, told the LA Daily News, “This is a good approach for those who don’t feel comfortable going into a facility.”

For now the program remains limited to women because the county has not found a good home test for men, but Fielding did say they would look at that in the future.

Study: Male Circumcision Can Prevent HIV in Women

The results of a new study presented last week at the International AIDS Conference show that male circumcision can help reduce the spread of HIV among women as well as men. There have already been a number of studies that have shown that men who have been circumcised are at lower risk of contracting HIV. These results have led to interventions designed to increase the number of circumcised men in areas of Africa with a high prevalence of HIV. But until now, researchers were not sure whether such interventions also affected HIV rates in women.

This new study looked at women in Orange Farm, a town of 110,000 people outside of Johannesburg, South Africa. (One of the studies on male circumcision had taken place there as well.) Researchers surveyed 4,538 sexually active women ages 15 to 49 in three waves, in 2007, 2010, and 2012.

Participants were asked a number of questions about their sex lives, including the age at which they’d first had sexual intercourse, the number of lifetime partners they’d had, whether they’d always used condoms, and whether their partners were circumcised. Researchers also took blood to test the women for HIV. Among the 1,363 women who reported only having had circumcised partners, the HIV prevalence was 22.4 percent, compared with 36.6 percent among the remaining 3,175. According to analyses conducted by the researchers, this means that having only circumcised partners reduced these women’s risk of contracting HIV by 16.9 percent. Moreover, when researcher looked only at women under 29, they found a risk reduction of 20.3 percent.

Kevin Jean of the French National Institute for Health and Medical Research conducted the study and presented the results at the conference. He told the audience that the results provide a “compelling argument” to speed up interventions that provide voluntary male circumcision in areas with high rates of HIV.

Australia Approves Condom With STI-Killing Microbicide

Australian condom manufacturer Ansell, which makes LifeStyles brand condoms, has just won approval to start mass production in its home country on a condom lubricated with a microbicide that inactivates sexually transmitted viruses. Called Viva-Gel, the microbicide binds to viruses, preventing them from interacting with human cells. Viva-Gel has been shown to disable 99.9 percent of herpes, HIV, and human papillomavirus (HPV) cells on contact.

While this the gel should add extra protection for couples using condoms, many are still hoping that something will be released as a vaginal gel to help women—especially those whose partners refuse to wear condoms—protect themselves from STIs. It is not yet clear when such a product would be available, but Viva-Gel is in phase 3 clinical trials in the United States for use as a cure for bacterial vaginosis, a common infection caused by an imbalance of “good” and “bad” bacteria in a woman’s vagina. Though not an STI on its own, there is some evidence that sex, new sex partners, and multiple sex partners can contribute to an imbalance of bacteria in the vagina. More importantly, however, bacterial vaginosis can leave women more vulnerable to infection with other STIs.

The condom will be sold in Australia under the name LifeStyles Dual Protect. A Japanese condom-maker has also been approved to begin adding this microbicide to its condoms.

HPV Vaccine Rates Still Too Low

New data on vaccines among adolescents shows that despite a modest increase in overall vaccination coverage from 2012 to 2013, estimated coverage for the HPV vaccine remained low. In 2013, 57.3 percent of girls had received one dose of the HPV vaccine, compared to 53.8 percent the year before. More girls had received all three recommended doses in 2013 than in 2012 (37.6 percent, compared to 33.4 percent), but the CDC says this is still too low. In fact, the agency notes that if all pre-teen and teen girls got the HPV vaccine when they got other recommended vaccines for their age group (such as the vaccine for meningitis), 91.3 percent of all 13-year-old girls would have at least gotten the first dose. The actual numbers fall far short of that.

Vaccine coverage for young boys is even lower, but there was a bigger increase (13.8 percent) in the number of boys who got at least one dose of the HPV vaccine—it went from 20.8 percent in 2012 to 34.6 percent in 2013. There was also an increase in the percentage of boys ages 13 to 17 who had received all three doses (from 6.8 percent in 2012 to 13.9 percent in 2013).

The CDC pointed out that these data reflect great variation in vaccine rates between states. For example, only 39.9 percent of girls in Kansas received at least one dose, compared to 76.6 percent of those in Rhode Island. Similarly, only 11 percent of boys in Kansas received one dose, compared to 69.3 percent of boys in Rhode Island.

The slow uptake of the HPV vaccine is disappointing, as it has been shown to be very effective in preventing the strains of the virus that are most likely to lead to cervical cancer. A 2013 study, for example, found that the proportion of girls infected with the strains of the virus addressed by Gardasil (the first of the two HPV vaccines introduced) dropped from about 12 percent before the vaccine was available to 5 percent, which represents a drop of 56 percent. The drop applied to all teens, whether or not they were vaccinated. This may be a result of what public health experts refer to as “herd immunity”—if enough of the population is protected by a vaccine, that protection extends to the unvaccinated as well. Among girls who had gotten the vaccine, however, the drop in HPV infections was even higher, at 88 percent.

We can only imagine how far we could go in preventing HPV and cervical cancer if more young women and men were vaccinated. Unfortunately, some people still see the HPV vaccine as controversial since it protects against a disease that is sexually transmitted and because the recommendations suggest girls and boys get it as young as 9 to ensure that they’ve received all three doses before they become sexually active.

Commentary Sexual Health

Illinois Governor Signs New Sex Education Law, But Some Abstinence-Only Proponents Say They Aren’t Worried

Martha Kempner

Illinois Gov. Pat Quinn recently signed a law requiring all schools in the state that teach sex education to include accurate information about birth control and STDs. This is quite a change from the current state law, which emphasizes abstinence, still, many are saying that schools—even those who use abstinence-only curricula—will not have to change much.

CORRECTION: A version of this article incorrectly noted that Gov. Quinn was planning to sign the sex education law. In fact, he has already signed it. We regret the error.

Illinois Gov. Pat Quinn has recently signed a law requiring all schools in the state that teach sex education to include accurate information about birth control and sexually transmitted diseases (STDs). While this is quite a change from the current state law, which emphasizes abstinence, many are saying that schools—even those who use abstinence-only curricula—will not have to change much.

Illinois law does not require schools to provide sex education but currently says that those that do must teach that “abstinence is the expected norm in that abstinence from sexual intercourse is the only protection that is 100% effective against unwanted teenage pregnancy, sexually transmitted diseases, and acquired immune deficiency syndrome when transmitted sexually.”

There are 860 school districts in Illinois and no state agency tracks exactly what kind of sexuality education, if any, each provides. A 2008 study by the University of Chicago, however, found that 93 percent of the districts offered sex education and about 65 percent of those that did, offered programs that the researchers considered to be comprehensive, in that the programs included discussion of contraception and STDs.

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Still, lawmakers are concerned that students are not getting enough information about these important topics. The goal of the new law is to ensure that students get medically-accurate and age-appropriate information about how to protect themselves against pregnancy and STDs. Sen. Heather Steans (D-7th District), who co-sponsored the legislation, told the Associated Press, “Abstinence is the only 100 percent effective way, but the reality is that by the end of senior year in high school, two-thirds of our kids are saying that they’ve had sex.” She added, “For me it really is best practices and what actually works.”

The law is expected to go into effect in January, but many school officials don’t believe it will have too much impact on what they will teach this coming school year. Tammie Holden, the principal of a middle school in Springfield, told the AP, “We’re still at the learning stage and understanding specifics. I don’t think we would have to do a new curriculum. So it would just be some adjustments made.” Similarly, Andrea Evers, the superintendent in Cairo, said her district already teaches a comprehensive program. “My belief is that we’re already doing it right,” Evers said. “Looking at both sides of the issue and making sure the children know that the choice is theirs.”

While these school districts may very well be within the parameters of the new law, some in the state are arguing that even those schools that take a strict abstinence-only-until-marriage approach will not have to make changes. Scott Phelps, executive director of the Abstinence and Marriage Education Partnership (A&M Partnership), a Chicago organization that sells abstinence-only curricula, told the AP that his clients are okay because they teach contraception—“just not in great detail.” He went on to explain, “We don’t teach them how to use contraception, but we teach them what it is. We don’t see how our curricula would in any way violate the new law.”

Having reviewed a number of the curricula that Phelps has written and A&M Partnership sells, I don’t believe that they are within either the letter of the law or the spirit in which it was passed. The law requires medically-accurate information, but Phelps’ curricula rely on incomplete truths, innuendos, and fear to “teach” young people about STDs and contraception. For example, Navigator, which Phelps co-wrote, tells students that “any type of sexual activity can spread STDs from one person to another.” But the curriculum’s definition of sexuality activity defines it as any type of genital contact or sexual stimulation including, but not limited to, sexual intercourse.”

That is a pretty useless explanation of disease transmission.

After all, I can think of many behaviors that involve genital contact—such as sticking your hands down your own pants while your partner watches or letting your partner touch you through said pants—that carry no risk of STDs; and if we’re just talking about sexual stimulation, the list gets even longer. Unfortunately, neither Navigator nor Aspire, another curriculum which Phelps wrote, explain how STDs are transmitted any better than this. Instead, both focus their discussion almost entirely on the long-term health results of untreated STDs. (I do give Aspire credit for encouraging teens to get tested if they suspect they have an STD.)

More disturbing, however, is that both curricula try to convince teens that condoms will not protect them from STDs. In one faux critical thinking exercise, Aspire asks students whether they would tell a friend about to have sex with someone who had a known STD to use a condom or instead tell him/her just not to do it. In another “thinking” exercise, Navigator shows separate graphs of condom use and chlamydia rates for the years 1982–1995 and notes that both went up. It then argues, “if condoms were effective against STDs, the increase in condom usage would correlate to a decrease in STDs overall—which is not the case. Rather as condom usage has increased, so have rates of STDs.” This sounds logical and many students may buy it as proof that condoms are inadequate, but in truth the increased rates of chlamydia over that period are explained by widespread screening, more sensitive tests, and better reporting.

While Phelps’ may believe that he is within the parameters of the law, such misleading discussions of STDs are unlikely to have the effect that Illinois lawmakers are seeking—a reduction in the number of STD cases among young people in the state. (In 2011, 35 percent of chlamydia cases and one-third of all gonorrhea cases in Illinois occurred in young people ages 15 to 19.)

Phelps’ curricula also do a poor job of educating young people about birth control, perhaps because he and his co-authors don’t believe teens can be trusted to use it. The guidebook for Navigator, which is intended for adults not students, explains:

Navigator does not promote the use of contraceptives for teens. No contraceptive device is guaranteed to prevent pregnancy. Besides, students who do not exercise self-control to remain abstinent are not likely to exercise self-control in the use of a contraceptive device.

I’m not sure which angers me more—people who don’t believe that teens are capable of making good decisions or people who believe it is okay to deny them information in order to influence their decisions. (Or maybe it’s people who believe sexually active teens are untrustworthy and lack self-control.)

Not surprisingly, the discussions of birth control in these programs are designed to undermine students’ faith in contraception methods. Aspire, for example, suggests that condoms break and other methods fail and then tells students that no contraceptive method can prevent all of the “consequences” of premarital sex. In case you’re wondering, these include emptiness, loneliness, broken heart, anger, rage, pregnancy, STDs, AIDS, infertility, cancer, worry, fear/stress, regret, low self-esteem, confusion, child care/support, loss of income, reputation, and parental conflict, among others. I suppose I can’t argue with this statement on its face—condoms can’t prevent loneliness and people can still be angry even if they have an IUD in their uterus. Of course that’s not what these methods were intended to do. To me, this tactic is akin to a magician’s slight-of-hand; instead of telling students that there a number of reliable methods of birth control that can help them prevent pregnancy, and one that also protects against STDs, the curriculum takes out a bright shiny object (or, in this case, depressing and scary objects) and says, “Hey, look over here.”

Curricula like these had their days in the sun a few years ago when the federal government was pouring money into abstinence-only-until-marriage programs and states were passing laws like the one currently on the books in Illinois that told schools to stress abstinence over anything else. Today, we know better. Research has found that these programs simply don’t work and states have wised up and passed laws, like this one supported by Gov. Quinn, that suggest a more comprehensive approach and require accuracy. According to the National Conference of State Legislatures, 19 states required schools that choose to teach sex education to provide medically-accurate information as of March of this year.

The fact that Illinois will be joining this list come January is great for young people there. However, it is important that groups like the A&M Project are not allowed to continue teaching their brand of abstinence-only-until-marriage programs or claiming that these meet the law’s requirements. These programs are neither medically accurate nor comprehensive and they cannot be considered sufficient education for the students of Illinois or any other state.